Healthcare Provider Details

I. General information

NPI: 1265430862
Provider Name (Legal Business Name): SAMUEL H ROSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2097 HENRY TECKLENBURG DR STE 211W
CHARLESTON SC
29414-5739
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-958-2555
  • Fax: 843-402-1961
Mailing address:
  • Phone: 843-789-1620
  • Fax: 843-724-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number10866
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: